TABLE 1

Clinical Documentation Framework Based on Core Components of Pediatric Care

Core Component of Pediatric CareExamples of Supporting EHR Documentation
LongitudinalSupport documentation over the life course of the patient: attainment of developmental milestones (even outside typical norms); physical growth (growth charts); and serial immunizations (eg, DTaP vaccine No. 2).
PreventiveSupport the attainment, documentation, and review of measures designed to maintain health: immunization schedules and screening tools and testing.
Age basedDocument and review data based on patient age: screenings, testing, and measurements and anticipatory guidance.
Pediatric condition specificDocument and review data based on patient conditions: dedicated growth charts for patients with conditions affecting growth parameters (eg, Down syndrome, prematurity) and documentation templates that guide assessment of patients with specific conditions (eg, evaluation of asthma severity or control for patients with asthma).
Patient and family centeredDocumentation supports the family unit and includes patient and family input: shared or linked mother-infant records to support perinatal care and documentation, shared family and social history documentation across family members, integrated patient- and family-generated data and/or information, supporting adolescent confidentiality, making information such as immunization records available to patients, families, and their providers regardless of the site of receipt.
Team basedShared documentation tasks across health care provider types, primary care and specialty physicians, and health care settings (ambulatory, acute care, and long-term care).
  • DTaP, diphtheria and tetanus-acellular pertussis.